I Think I my CPR Instructor Didn't Know What She Was Talking About

[darobow]

I am a CNA/CMA in Oklahoma and I have taken paramedic training so I know CPR and this isn't an ego thing where I disagreed strongly to the point where I am crying to the internet. It was to the point where we were basically handed out books at the facility I work at detailing what we can and cannot do with first aid/cpr however the instructor was saying the total opposite!

The books we were given detailed CPR and First Aid and the use of tourniquets however my instructor said that since we were lay people that we could only do direct pressure and that applying tourniquets was out of the scope of practice for us. (I haven't been able to find anything to back that claim up)

I was a bit confused but rolled with it anyway I didn't think CNA/CMAs were lay people since we are trained?

I was reprimanded for going over 100 compressions in one minute (I did 140) and I asked why that was a problem "Is for my benefit to straddle 100 for stamina sake until EMS arrives? Or am I doing damage to my patient?"

She gave me some sort of strange explanation that didn't really explain anything stating "If you go too fast the blood and oxygen goes through the body to fast to perfuse..."

I thought that was weird since you make up 25% percent of the heart doing chest compressions.

At the end of the class I apologized for pressing questions so hard about the tourniquets and said "This is my first time learning CPR and First Aid from this perspective I was taught the EMT way first and when I was told to not apply tourniquets if the bleeding continues I panicked a little and I'm sorry."

She replied "Well would you violate scope of practice?" I stared blankly at her for a minute and said "no"

Have they added tourniquets for just EMS!? I cannot find anything backing this up.

I am thoroughly confused over this and am worried that I could be putting clients' lives in danger if I listen to this woman.

Thoughts? Opinions? Am I wrong?

[Triddin]

If the bleeding doesn't stop with appropriately applied pressure to a compressionable arterial site, the patient needs surgery ASAP. Being at a facility, I would hope that if a patient was bleeding that much, that you would be calling 911 to get the patient to the hospital. So I don't disagree with your for instructor that it is out of your scope. I would expect your RN consultant being the one to apply pressure.

[klone, MSN, RN]

Well I work at a facility where most of the staff are nurse aids and have an RN consultant. My issue was "Where do we go from here if the bleeding continues if direct pressure doesn't do anything and are there alternatives since we cannot use tourniquets?"

You call 911 and ship the patient to an acute care facility.

[darobow]

Sour Lemon it was also FIRST AID TRAINING and I was just asking questions like a student should. And not getting any answers. So I was lead to believe if somebody has a grievous wound call 911, apply direct pressure to stop the flow of blood. But what should I do if they continue to bleed while EMS is coming with direct pressure applied!? We are all Nurse Aids on shift there are no RNs on shift just an RN consultant that comes by the facility occasionally. I guess I'll let them bleed out if they continue to bleed with direct pressure applied. While EMS is on the way fingers crossed they get there in time God forbid

[Triddin]

If it continues to bleed while applying direct pressure, you aren't applying pressure correctly.

[Horseshoe, BSN, RN]

Sour Lemon it was also FIRST AID TRAINING and I was just asking questions like a student should. And not getting any answers. So I was lead to believe if somebody has a grievous wound call 911, apply direct pressure to stop the flow of blood. But what should I do if they continue to bleed while EMS is coming with direct pressure applied!? We are all Nurse Aids on shift there are no RNs on shift just an RN consultant that comes by the facility occasionally. I guess I'll let them bleed out if they continue to bleed with direct pressure applied. While EMS is on the way fingers crossed they get there in time God forbid

I have worked a post cath lab unit where we pull large catheters out of the femoral artery. In addition to pulling sheaths, I've witnessed the arterial plugs come loose when a patient sat up against instructions, with the artery bleeding with such force that there was blood on the ceiling! Never once in the years I worked that unit was direct pressure insufficient to stop bleeding, and we are talking about a patient population who are all on anticoagulants.

Apply direct pressure, call 911, and you won't need to do anything else.

[RotorRunner]

Okay, I'll bite. What kind of wound are you expecting to encounter in the assisted living setting that would benefit from a tourniquet? I'm a flight nurse and have used a tourniquet only a handful of times for extremity amputation. Most bleeding will be slowed enough with direct pressure to give you time until EMS arrives. Tourniquets, when improperly applied, can cause severe damage to the patient.

[Buckeye.nurse]

I can't speak as to the tourniquet question, but I can answer your question on chest compressions.

Just a touch of background--I am a BLS instructor with the American Heart Association, and teach the blitz classes at my hospital. There weren't a ton of updates in 2015, but one of them *was* the rate of chest compressions. We used to say to compress at a rate greater than 100.

Here's the problem. People get into code situations. Their adrenaline starts pumping, and before you know it they are compressing at rates of 140, 160, even 180 per minute. We have the feedback technology to measure this stuff now, as well as the technology to measure perfusion. When compressions get that fast, it's pretty much impossible to allow complete recoil. If the heart isn't allowed time to refill, then you aren't circulating much with the next compression.

With all that being said, the new recommendation is to compress at a rate of 100-120 bpm. Our lead instructor has asked us to emphasize it strongly in blitz sessions so that people get into the habit of compressing a bit slower. Hope this helps!

[darobow]

Okay, I'll bite. What kind of wound are you expecting to encounter in the assisted living setting that would benefit from a tourniquet? I'm a flight nurse and have used a tourniquet only a handful of times for extremity amputation. Most bleeding will be slowed enough with direct pressure to give you time until EMS arrives. Tourniquets, when improperly applied, can cause severe damage to the patient.

I just don't want to rule out the possibility. I know that more than likely I would not need to use one. I am a bit of a 'dark cloud' though. Obviously nobody is gonna get amputated at an assisted living facility. I'm just concerned over the fact that there is no plan B that I can fall back on.

[JKL33]

CPR/BLS, ACLS, etc...none of these are a rockstar contest.

Ideally you would have gone to the class with an open mind, since you have a knowledge deficit.

As far as the tourniquets, those of us who may have occasion to use them receive more detailed instruction on their use, and regular review.

Your employer has not delegated this skill to you, and CNAs do not make independent decisions about emergency treatments. End of story. You are not very likely to encounter a situation that requires a tourniquet - - you should focus on trying to understand the topics that were presented to you which you are more likely to encounter.

[Triddin]

But that's like saying I want to know what your plan b is if compressions don't work. Applying pressure is the answer. However, if you don't trust the word of those of us with experience, do a literature search and see what peer reviewed papers state

[akulahawkRN, ADN, RN, EMT-P]

Every basic first aid course I have ever attended has addressed the use of tourniquets. In short, if direct pressure does not stop bleeding in a limb (and the vast majority of the time it does), then you step up to using a tourniquet. It has to be a wide band style or you will cause tissue damage under the tourniquet before you stop blood flow. Notice I did not say to use pressure points? That's because those were taken out of the sequence for bleeding control. They do work but if you're using that technique, it should only be because you're in the process of placing a tourniquet.

And no, tourniquets are NOT just a "military thing."

I am both an RN and a Paramedic. I do know bleeding control. What I also know is that your employer gets to set your scope of practice while you're at work. I'm trained to do a LOT of things, some of which are NOT authorized for California Paramedics, some of which are not authorized by my local EMS agency. If your employer doesn't authorize you to use a tourniquet, then you are not allowed to use a tourniquet while you're at work. Quite frankly, if you have a patient that is bleeding so heavily that a tourniquet is needed, you'd better have already called 911... Once those folks arrive, they take over and they get to function under a different set of rules than you do.

Also, sometimes it's just better to grin and nod because you know a lot more than your instructor does (easily possible with CPR/First Aid courses) and investigate what your scope of practice really is while at work and follow that scope of practice.

[darobow]

Every basic first aid course I have ever attended has addressed the use of tourniquets. In short, if direct pressure does not stop bleeding in a limb (and the vast majority of the time it does), then you step up to using a tourniquet. It has to be a wide band style or you will cause tissue damage under the tourniquet before you stop blood flow. Notice I did not say to use pressure points? That's because those were taken out of the sequence for bleeding control. They do work but if you're using that technique, it should only be because you're in the process of placing a tourniquet.

And no, tourniquets are NOT just a "military thing."

I am both an RN and a Paramedic. I do know bleeding control. What I also know is that your employer gets to set your scope of practice while you're at work. I'm trained to do a LOT of things, some of which are NOT authorized for California Paramedics, some of which are not authorized by my local EMS agency. If your employer doesn't authorize you to use a tourniquet, then you are not allowed to use a tourniquet while you're at work. Quite frankly, if you have a patient that is bleeding so heavily that a tourniquet is needed, you'd better have already called 911... Once those folks arrive, they take over and they get to function under a different set of rules than you do.

Also, sometimes it's just better to grin and nod because you know a lot more than your instructor does (easily possible with CPR/First Aid courses) and investigate what your scope of practice really is while at work and follow that scope of practice.

Thank you so much! You sir, Miss? have answered alot of my questions! I will look into what my scope of practice is at my facility!